E-Cigarettes and the Many Hazards of Vaping – PediaCast 508

Show Notes


  • Drs Grace Paul and Eric Mull visit the studio as we explore e-cigarettes and the many hazards of vaping. Millions of American youth vape on a regular basis. We consider the dangers and discuss strategies for decreasing the impact of this addictive epidemic. We hope you can join us! https://bit.ly/3sdNaD1


  • E-Cigarettes
  • Vaping




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.


It's Episode 508 for December 15th, 2021. We're calling this one "E-cigarettes and the Many Hazards of Vaping". I want to welcome all of you to the program.


And in particular, welcome to our final installment of PediaCast for the year 2021. Of course, we have lots more in store for you in 2022 with many of our topics locked in and scheduled. And I want to tell you, we have some really interesting episodes that I will be excited to share with all of you after the New Year.




Things like safe driving for teenagers, bedtime problems, that's always a popular topic for tired parents. Zero suicide initiative, and interview with the editor-in-chief of Highlights for Kids, which lives up at the top of my personal list of all-time favorite magazines.


We're also going to demystify genomic medicine in 2022 and tell you about an interesting research study involving emergency care for children who are having seizures.


We also have plenty of open spots in 2022, so if there is a topic that you'd really love to hear us explore, let us know. Just use that Contact page over at pediacast.org.




Now, before I get ahead of myself, it is still 2021. And the holiday season remains before us. And so, I would like to sincerely wish all of you, the PediaCast listeners, the happiest of holidays, as you safely gather with family and friends in whatever way your family celebrates the season. Truly, truly, I really do wish all of you the merriest of holidays, really appreciate you continuing to be a part of the PediaCast family.


All right, so what do we have in store for this final episode of the old year? Well, I gave it away in the title of our episode. We are exploring e-cigarettes and the many hazards of vaping. Now, you may recall, prior to the COVID-19 pandemic, we were in the midst of a vaping epidemic among American youth, with over 5 million middle and high school students reporting regular use of e-cigarettes in 2019.




Now, there is some good news to report as we consider the numbers. The COVID-19 pandemic led to a reduction in a number of youthful vapers. But there's still too many children and teens smoking e-cigarettes. I mean, any number is too many.


But in fact, this year, 2021, 11% of all high school students and 3% of middle school students report the regular use of e-cigarettes. So, we're still talking about millions of kids.


Now, you may be asking, what's the harm? Aren't e-cigarettes safer than using tobacco products? Well, the answer to that question in some ways, yes, they are safer. But in other ways, they just simply represent a different set of hazards which are equally bad.


And so, we're going to explore those today. In our typical PediaCast fashion, we do have two terrific studio guests to help us ponder the problem. Dr. Grace Paul, she's a pediatric pulmonologist, which is a lung specialist, at Nationwide Children's Hospital. And Dr. Eric Mull, he is a pediatric pulmonary fellow. So, he is in training to become a lung specialist, also at Nationwide Children's.




Before we get to them, let's run through our usual quick reminders. Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google Podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


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And as I mentioned, there's that handy contact page over at pediacast.org, if you would like to suggest a future topic for the program.


Also, I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.


Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.


So, let's take a quick break. We'll get Dr. Grace Paul and Dr. Eric Mull settled into the studio and then we will be back to explore e-cigarettes and the many hazards of vaping. It's coming up right after this.






Dr. Mike Patrick: Dr. Grace Paul is a pediatric pulmonologist at Nationwide Children's Hospital and an assistant professor of Pediatrics at the Ohio State University College of Medicine. She also serves as the Ohio Chapter of the American Academy of Pediatrics, their e-cigarette champion. Dr. Eric Mull is a pediatric pulmonary fellow at Nationwide Children's and Ohio State.


They've been following the vaping epidemic among American youth with close interest, as they care for children and teens with lung complications secondary to the use of e-cigarettes.


That's what they're here to talk about, e-cigarettes and the many hazards of vaping. But first, let's give a warm PediaCast welcome to our guests, Dr. Grace Paul, and Dr. Eric Mull. Thank you both so much for being here today.


Dr. Eric Mull: Yeah, thank you for having us on.


Dr. Grace Paul: Thank you very much.


Dr. Mike Patrick: Really appreciate you taking time out of your busy schedules. And I will say this is a PediaCast first in a really long time. We are actually in the studio together, rather than doing this virtually. So, it's really good to be back here in the studio and actually seeing my guests in person. So, thank you for being the first ones back.




So, Eric, I wanted to start with you. Let's just begin with definitions. What exactly are e-cigarettes and vaping?


Dr. Eric Mull: Yeah, of course. So, e-cigarettes are relatively new device when you compare them to conventional cigarettes that had been on the market for many decades. E-cigarettes first came into existence back in 2003 from China, when a Chinese pharmacist's father actually died from lung cancer and he wanted to create a device to help individuals kind of come off of smoking as an addiction.


They were first introduced into the US market back in 2006. And they've been here ever since, kind of slowly building. They are what we are considering electronic nicotine delivery system devices, which are acronymed as ENDS. And they are devices that since their inception back in 2006 in the US market, there are currently almost over 300 type of products that serve for the definition of electronic cigarettes that individuals can use and utilize.




Dr. Mike Patrick: So, this really just has the liquid which has nicotine in it, along with some other things which we'll talk about. And then, it creates a really fine mist, like there's a little motor in there and the battery. So, it's like a little machine, right?


Dr. Eric Mull: Yeah. So, when you get down to it, there's really three main components to electronic cigarettes. There's the vaping cartridge, so whatever houses the liquid filled with nicotine flavor. There's also the atomizer, which heats up the solution, then a battery. And those are the three main components that contributes towards a vaping device. 


Dr. Mike Patrick: And some of these are refillable, but there's also closed systems that are just disposable after. I mean, they come in really lots of different ways and flavors. And again, we'll talk more about that. Really, it's just been an explosion of types of e-cigarettes that are out there.


Dr. Eric Mull: Correct, yeah. Since probably the early 2010s, there's been an explosion with this type of devices. They come in various sizes, as small as a USB drive or as large as something that's handheld with a large palm like a cellphone type of device.




Dr. Mike Patrick: Yeah, got you. And its primary goal is nicotine delivery but without the carcinogens that we would see with tobacco smoking. 


Dr. Eric Mull: Like everything, it had good intentions when they were first being created with a goal to kind of stop traditional cigarette use and help people that are in a vice and are not able to come off of those products. But they've since evolved to come into their own problems themselves. 


Dr. Mike Patrick: Yeah, someone saw they could make money and if you just use them to get people off cigarettes and then stop, then you're not selling them anymore. And so, you want to sell more of them. That's from the vantage point of the companies making these things, that's their goal, is to make money.


So how common then is vaping among American youth? How big of a problem is this?


Dr. Eric Mull: So, every year, the FDA, they do this survey which is called the National Youth Tobacco Survey. And it really surveillances the prevalence of these devices, whether it's traditional cigarettes or vaping in schools.




Before the pandemic in 2018, 2019, it was fairly prevalent. About 20% of high schoolers said that they at least used a vaping device once during the year, with a percentage of that percentage saying that they've used it multiple times within a month.

And then since the pandemic, we've actually seen a slight decline which is great. But it is still fairly a prevalent issue.


Dr. Mike Patrick: Absolutely. The numbers that I saw from that survey that you were talking about, for 2021, it was about 2 million US middle and high school students reported using e-cigarettes in 2021. And that's 11% of all high school students which is about 1.7 million high school students regularly using e-cigarettes in the past year.


And then about 3% of middle school students, so we're still talking hundreds of thousands of middle schools’ students who are using vaping devices. 


But how does that compare to let's say 2019? There are a lot then. I think it's over 5 million American school children that were using vaping devices back then, right?




Dr. Eric Mull: Yeah, so over 3 million in high school and that left about 2 million in the middle school. So, as you can see, these devices are reaching even to the youngest of our population that are old enough to obtain this type of devices and use them properly.


And so, it has been a prevalent issue. We've been seeing some changes thankfully because of the pandemic, mainly because of resources, able to get the product. And there's a lot of different factors that have been going to see the decline and which I'm happy to go into.


Dr. Mike Patrick: Yeah, please do. I mean, to go from 5 million down to 2 million is pretty remarkable, really. I mean, we'd like it to be zero, obviously. We'll talk about why that is and why they're dangerous and the many hazards. So, 2 million is too many, but compared to 5 million, it is definitely an improvement.


However, kids are back in school and we start normalizing things, which over the next year too, hopefully, that's going be the case, it would be really easy for that to just bump right back out there without some interventions, right?




Dr. Eric Mull: Yeah, exactly, the FDA, Federal Drug Association, is the agency that regulates this product. And they're doing their best for what they can for limiting the use in underaged population. They restrict the purchase of them to 18 years or older, certain states can also restrict it further.  Here in Ohio, it's restricted to 21 years and older for sale.


And so, what we're seeing with what we think for the decline in use in the high school population is, one, they're not with their peer population while they were virtual learning from home. So, they don't have that peer pressure, that social exposure. They may not be able to get the resources from their peers too as well because they're isolating from them.


Also, during the pandemic, retail stores for vaping shops have also kind of closed and shut down. And then, depending on where you are statewise, there is different guidelines and restrictions for online sales which have also reduced the use of vaping products.




But these again, those are things that sound reversible once the pandemic is over, I mean the shops can open back up. Kids in schools, they may have a friend, who now they're around all the time again. And they may be vaping and may influence them to start vaping. And so, we really do have to keep our eyes open and, on our toes, to keep those numbers form creeping back up.


Now, the COVID pandemic though, it has decreased the number of kids who are vaping. But because COVID causes lung disease and lung infections, I would suspect that maybe the complications that you can get which we're going to talk about more in a minute. But the pandemic has also impacted, just that it's a respiratory pandemic and vaping is a respiratory problem.


Dr. Eric Mull: Yeah, right before the pandemic hits in March 2020 was just the start where we were starting to see that EVALI, the Electronic Vaping Associated Lung Injury disease. And so, I think there was a lot of awareness with the community about the dangers of vaping. That it's not this benign product that people can use to make smoke rings and do tricks with it or even get flavors.




So, I think that the public was starting to get this awareness that these products aren't as safe as they were marketed to be. And I definitely think, with the pandemic, it being a respiratory illness has also brought the consciousness of people that can further cause issues.


Dr. Mike Patrick: Absolutely. So, Dr. Grace Paul, I wanted to bring you in. Tell us how is vaping similar to tobacco cigarette smoking. And then we'll talk about how they're different.


Dr. Grace Paul: Thanks, Mike. So, one of the big things is the first generation of e-cigarettes that they created, first, they looked very similar to our traditional cigarettes. So, it was just one marketing strategy that they had.


And all of these, both of these devices are heat-activated devices. So basically, it's like either burning these tobacco leaves in the cigarette or the liquid, which contains nicotine and other chemicals. The chemicals that are released are highly addicting and all of them cause significant cardiac or pulmonary morbidity.




So, the aerosols that are released from both these devices do alter your airway epithelial immunity, so predisposing to more viruses and more bacterial infections, including COVID. So that is a concern. So, I would say it was sort of like with cigarettes, it's a known poison. And with e-cigarettes, it's sort of like you're learning about this new poison, so they are similar in that way.


The other side is from a business angle. The tobacco companies are proactively marketing for both these products, cigarettes, and e-cigarettes. And an enormous amount of money is spent to propagate sales.




But on the other hand, the many many organizations and institutions are again actively focusing on education, advocacy, and interventions to curve both these uses. Those I feel are some of the similarities between these two products.


Dr. Mike Patrick: So, I mean, ultimately, the goal is to get the nicotine in the body. And when you start doing that, the body is going to crave the nicotine. And we'll talk more about why that is in a little bit and the effects of nicotine. But regardless, you're trying to get nicotine into the blood and to the brain ultimately.


But then, how are they different? You mentioned that there are products other than the nicotine in the vaping juice that we use. What are some of those products?


Dr. Grace Paul: So apart from pure nicotine and the e-liquid, what is attractive is that the liquid can be customized. A consumer or user can do whatever they want. They can add marijuana, they can add any other chemicals, flavors. Each comes with, because of deceptive marketing, we are not sure what exactly is in there. But each liquid comes with a side effect which nobody talks about.




So that is something which can be done with e-cigarettes. Another point that's different from a cigarette is there is no combustion or tobacco smoke release. But here, it's an electronic device, maybe actually heating a metal also. So apart from just like the aerosol released from the liquid, it's also chemicals released from heating a metal. So, there is sort of a double danger here that's happening.


The other thing we have noticed is sort of an acute onset of symptoms with e-cigarette use. So, with cigarettes, we know a lot of symptoms are like sort of chronic. But with EVALI, some of these are just like first-time use. There's significant lung damage.


And I've been seeing like rapid onset of like even up to something like bronchiectasis happening with a sharp usage. So, and then again, it being an electronic device, there are explosions. The device just burst. And that's something also that's different from routine traditional cigarettes.




Dr. Mike Patrick: Absolutely. Interesting point with the heating the metal. You think about fire fighters going into a burning building and there's metals and chemicals that are very toxic to the lungs that can get emitted in the smoke. And we hear about firefighters having bad lung disease.


And so traditional cigarettes don't have burning metal inside of them releasing those kinds of chemicals as these do. So, they're just different hazards, right?


Dr. Grace Paul: Yes.


Dr. Mike Patrick: And if you look at some of the combustion products in tobacco cigarettes, things like benzene and arsenic and butane and formaldehyde to tar, those are all bad in terms we know can cause cancers and can be directly toxic to lung tissue as well. But you may be surprised to know that some of those same products are also in many vaping juices, although it varies by brand. But you will find many that do contain lead and toluene and formaldehyde and the polyethylene glycol. And the glycerins can be bad for the lungs.




And so, these are not necessarily just water and nicotine. There's really more to them that folks should know about. And really, it's a very toxic exposure that's just a different toxic exposure.


Dr. Eric Mull: Exactly.


Dr. Mike Patrick: Now, how does the nicotine itself compare? I know different brands of cigarettes have different concentrations of nicotine that you get exposed to. But I think, in general, I've heard you get about 1 to 2 mg of nicotine per cigarette. Although there may be 8 mg of nicotine in the whole thing. But in terms of exposure and what gets inside the body, it ends up being about 1 to 2 mg.




And so, the vaping folks would say that one hit is often equivalent to one cigarette. But I guess the thing to remember is that it's easier to take multiple hits off of the vape than to light up a new cigarette and take out the packet and all that. So is the total exposure to nicotine, does it tend to be greater with vaping or not really?


Dr. Grace Paul: So, one of the very popular products is the Juul. Again, it seems such a harmless device, but then 1 Juul pod is equal into 20 cigarettes, actually. So that's a lot you just don't realize you're taking. If you show a kid 20 cigarettes, and "I'm going to use it." But then, if you show this Juul, they don't know what's in it. So, it definitely varies between products.


Another thing about the e-cigarettes is you can't control how much you inhale, like the puff strength or the intensities. Bottles varies in how much nicotine goes into your lungs with each breath that you take.




Dr. Eric Mull: And to add on to that, Dr. Paul is exactly right, there's a lot of user variability that impacts how much nicotine an individual gets. Unlike a standard conventional cigarette where it's just one stick and that's all you get, that's how much you use. With these pods, they have a lot of volume, so it really depends on what the flow rate is of people breathing in, breathing out, how long they're holding their breath, what is the puff duration. And so, there's definitely a lot of variations that the user can do to vary how much nicotine their body's obtaining.


Dr. Mike Patrick: And the reason this is important is because nicotine has many effects on the body and so we're very interested in how much nicotine you're being exposed to when you do vape.


So, let's talk about that. What exactly is nicotine and how does that affect the body?


Dr. Grace Paul: So, nicotine is basically a highly addictive chemical compound from the tobacco plant. When inhaled, it rapidly gets absorbed and delivered to the brain. And in a developing brain, as in in adolescent, it can mess with the key receptors in the brain and causes increased addiction. There's a high addictive potential.




Kids use it mainly as a stimulant, as an anxiolytic, so the first puff maybe calms them down. But the nicotine addiction sets in, it's very hard to get rid of it.


Side effects of nicotine, you know, again, multiple, it affects all body systems. From a respiratory system, main thing we see, the worst thing is it's a carcinogen, it can cause cancer.


Acutely, it can cause bronchoconstriction. So, kids can have like wheezing, coughing bouts. A lot of it's an airway irritant, so there's lot of mucus and cough and phlegm. So that's from a lung standpoint.


And long term, we know it does cause COPD and the same, a lot of lung problems. From a cardiac standpoint, it increases your heart rate, your blood pressure, increases your tendency to clot and form atherosclerosis. And it also reduces cardiac coronary profusion. So, there's like multiple angles it hits.




From a neurological standpoint, this is just purely nicotine and not even the other chemicals, right? Because it's highly addicting, so kids not only tend to be addicted to nicotine, but it increases your susceptibility to be addicted to other drugs also.


So that's one issue. We do see a lot of psychosocial issues, anxiety, depression, aggressive behaviors, changes like that.


And one last thing that we're really concerned about is, at home, if there's nicotine liquid, if a child ingest that, it can actually be extremely dangerous. For example, a vial has only 5 ml of nicotine, but that's equal to almost like 200 ml, the lethal dose is only 10 ml.




So, a child if they just take .5 ml, that could be lethal. So that's one of the reasons for high volume of calls to the poison center because a kid accidentally took the parent's e-liquid or e-juice.


Dr. Mike Patrick: Really good point there. And I think that, of course, we would love for youth to not use e-cigarettes and to not vape. But at the very least, treat these things like a dangerous medicine, the vials, especially if there's young kids in the house. Because a two-year-old, three-year-old who's exploring, especially if it's a flavored one, it smells good, they take a drink, taste like cotton candy, and they can have a lethal dose of nicotine. And certainly, that has happened on many occasions.


And a lot of calls to poison centers, and so it's really important to keep that out of the way. Of course, we'd love for it to be out of the house completely, but definitely out of the reach of young kids.


So, I was to just kind of sum up because I think folks would find it interesting how nicotine really, how you become addicted to it. And there are, as you said, it's in the brain and it affects some neurotransmitters, which are some chemicals that help neurons in the brain talk to each other.




One of those is acetylcholine. And that is interesting because that particular neurotransmitter improves concentration and energy. And so, when you first start using nicotine, you feel great. You're able to concentrate on your schoolwork better. You have more energy, and this is why people want to start using it.


But then the body is like, wait, this is way too much acetylcholine. It's mimicking it. It's binding to those receptors. And so, your body starts to down-regulate those receptors so there aren't as many of them for the nicotine to bind on to. So, it doesn't have as big of an effect, which means you need to use more of it and more of it.


And then, when your body starts making less of that neurotransmitter, so then when you stop using the nicotine, your body doesn't right away start making more of the natural acetylcholine that you need. And so that's where the addiction comes in because you need the nicotine in order to function because your body is no longer making the chemical that the nicotine is kind of mimicking.




And so, kind of interesting how that process happens. And so, it is difficult to stop because you have to get your body making it on its own again.


And then, the other neurotransmitter that it mimics is dopamine. And we all dopamine helps with depression and anxiety in the short term. So, it may actually help with anxiety and depression when you first start using nicotine. But then again, you're going to down-regulate dopamine receptors and then you can have anxiety and depression problems once you're using inappropriate amounts of nicotine.


And then, the cardiac component of it is really where you get into life-threatening issues in terms of it causing elevated heart rate, elevated blood pressure, the risk for heart attack and stroke. And that's really where the lethality of it comes, is in the cardiovascular system.




So just it's an interesting chemical. And you can see why people start using it and then get themselves into trouble. But there are better ways to improve your concentration, and to improve your energy, and to improve your mood. And so, nicotine is not the answer. Probably counseling is a great way to deal with those things.


You mentioned that vaping was originally thought it was to help people stop smoking tobacco products. Is there still a role for it in that process, in terms of is that a good thing to vape to get off of tobacco cigarettes?


Dr. Grace Paul: So, at this time, the FDA has not approved vaping to be used as a quitting agent. But by experience and based on some studies, there is this thing that it could benefit adults who smoke, those who are not pregnant, if you use it as a complete substitute. So, you cannot be using dual vaping and cigarettes. But this rule is not applicable for youth, young adults, pregnant women.




So even though there is some harm reduction in terms of what chemicals are inhaled, it is only to those adults who smoke, and they are completely willing to stop traditional cigarettes. But still the ideal way to quit would be or evidence-based cessation therapy is counseling, nicotine replacement patch, and some cessation drugs like Chantix. That's what actually is approved.


Dr. Mike Patrick: So, if you want to stop smoking tobacco, which we would highly recommend, definitely talk to your doctor because there are safe ways to do it. And if you're going to do it through vaping, you need to be a non-risk adult. And you have to have some program where you're gradually using less and less of it, so that your body can start making the acetylcholine again at an appropriate rate. And so, you really need someone that's in charge of figuring out how you're going to do this.




But in terms of evidence based and what we know works, the nicotine replacement patches. I remember they have gum. Do they still make the nicotine gum?


Dr. Eric Mull: They do.


Dr. Mike Patrick: Okay. I remember before the patches, that was the big way to get the nicotine in, especially the patches. And having it supervised by a physician is really the best way to go about stopping using tobacco cigarettes.


So, Eric, let's talk about the short-term hazards of vaping. Why are we talking about this today, why do we want to get America's youth off of vaping?


Dr. Eric Mull: So, there's many short-term effects. I feel like I went into medicine and I feel like a lot of doctors have gone into medicine for this preventative care. And I feel like that's where we primarily could have that role in pediatrics.


So as Dr. Paul has mentioned, there is a lot of risks with nicotine, a lot of risk with inhalation injuries with long-term use. And if we can kind of stem that with the short-term use problems, then hopefully, we can prevent from any of that developing when they're adults and when they grow up.




So, some of the short-term issues that we worry about, it's just like with traditional cigarette smoke. Children are at increased risk of asthma exacerbation if they have baseline asthma. They're at increased risk of having coughing or wheezing just as symptoms. They're also at increased risk of respiratory illnesses too as well, whether or not that's from first-hand smoke themselves or second-hand smoke. All of this plays a role in the changes of the lining of the airway, irritation to the airway, making it prone to infection and illness.


And then, as you mentioned earlier, there's a lot of components still in electronic vaping devices, as opposed to traditional cigarettes, that still cause issues like formaldehyde which can cause pulmonary pneumonitis, which is a hypersensitivity of the airways, which can lead to respiratory distress and shortness of breath.


And then even in severe cases, we can have that electronic vaping-associated lung injury that we've been seeing hospitalizations for, especially right prior to the pandemic.




Dr. Mike Patrick: There's a great blog post on the 700 Children's blog online that's called Vaping Illness: What We Know About This Mysterious Condition. I'll put a link to that in the show notes so folks can find it easily. Really interesting article.


And then, Dr. Paul had mentioned that we don't know always what's in the juice. And so especially if you're buying it from someone else. Marijuana can be in it, other drugs. Fentanyl, heroin even can be in this thing if you're buying them off the street. And certainly, we have seen folks in the emergency department who come in with severe symptoms who thought they were just vaping nicotine and hear there was something laced in it. So that's a problem too, right?


Dr. Eric Mull: Yeah, exactly. And some of these chemicals can cause what are called like lipoid pneumonia which is a pneumonia based on fat products going into the lung and causing irritation. The problem with this disease condition is because they present very similar to an infectious process, so they mimic fever, systemic symptoms, shortness of breath, decreased oxygen levels when you check their blood.




And that could also lead to misdiagnosis of an infectious process and, ultimately, the wrong treatment which would delay their recovery. Which where we can see acutely some worsening of the respiratory symptoms, even to the point where they may need invasive ventilation for support.


Dr. Mike Patrick: So, folks can have a severe toxic lung reaction even if they just started using them. This isn't something like you have to use it for a long time before that happens. It could happen at any point when you're using these products, right?


Dr. Eric Mull: Exactly, correct.


Dr. Mike Patrick: So that makes it you're really gambling; you really roll in the dice when you use these products. And so, folks really need to understand that there is this significant risk within that we have seen with significant toxicity to the lungs from vaping products.


What then are the long-term hazards? Are these cumulative effects? Is there more risk down the road the longer you use it?




Dr. Eric Mull: Yeah. So, anything with inhalation can cause irritation to the airways. And some of the things that we've even been noticing short-term which we consider long-term issues is something call bronchiectasis. And that's where we get permanent dilation of the airways.


The airways are only supposed to be of certain caliber or certain length in diameter and width. And that helps us maintain that elastic coil in the areas when we cough, we're able to clear out secretions quite easily. But with this constant inhalation, inflammation, and irritation to the airways, you get narrowing of the airway walls and also widening of the airway spaces.


So, when you imagine if you're coughing, you're creating an increased negative pressure in your chest. Your airway's closed instead of keeping open to keep removing secretions. And so, you get secretions that are stuck in the bottoms of your lungs, difficult to remove out. And just like stagnant water, you're more prone to infections, accumulating bacteria and causing problems in the long run, respiratory-wise.




Long-term, otherwise, you can also get issues as Dr. Paul was mentioning, cardiovascular-wise. Nicotine cause issues with oxidative stress to the vascular system, leading to remodeling, leading to cardiovascular disease later in life. And then depending on where the adolescent population is getting their supply of cartridges or liquids, you don't know necessarily what’s with it or if it's been marketed with other products such as THC or cannabis, that can have its own effects too, long term.


Dr. Mike Patrick: So serious issues can rise both in the short term and the long term for those who are using vaping products. What about those of us who may be exposed to second-hand smoke? If you have someone in the house who's vaping, is that dangerous for them?


Dr. Eric Mull: Yeah, I think a lot of people are still under this notion, which is part of the why we're here today, is that vaping is this safer alternative to cigarette smoke. I see a lot of people in the community doing vaping or electronic cigarettes in areas where you traditionally wouldn't be seeing conventional cigarettes being used.




I've seen it in restaurants. I've seen it in theaters, stuff like that. And so, the smoke in vaping is different than conventional cigarettes, but it does still contain known substances that are carcinogens that causes issues.


And just because it's vape, people think it's steam, it's a little bit healthier, there's really no combustion to it. It still clings on to clothes, still clings under rags, sofas. And we've been seeing with our children population that we have in our clinic with asthma, some worsening asthma symptoms, asthma exacerbation, increased hospitalizations, increased oral steroid uses which is what we strive not to do. And so, we've been seeing some worsening symptoms for our patient population that we follow here.


Dr. Mike Patrick: When I see kids with a chronic cough in my practice, one of the things you ask, does anyone smoke in the house? And it just occurred to me, that might give someone a reason to say, "No, I don't smoke, I vape." But they may not say that, so maybe we should be asking specifically, "Are there any smokers in the house?" and "Are there any vapers in the house?"




Dr. Grace Paul: In our pulmonary clinic templates, we do have it, but I don't think it's a general practice to ask about vape also.


Dr. Mike Patrick: So, there you go, any pediatric providers who are listening, make sure you ask about vaping specifically and just don't assume that they will answer yes to the smoking question.


And then, we did mention already that young children are of particular risk if there's vaping in the house because of the fact that he could drink that juice and it can be lethal. But a really important point to talk about again.


All right, so Dr. Paul, I wanted to just kind run through the various ways in which these products are packaged and marketed. Because as you said, they started out looking more like traditional cigarettes. But that's not necessarily the case anymore and I think parents really ought to be aware of the different varieties of products that are out there so they can be on the lookout for them in their home.




Dr. Grace Paul: So yeah, that's the smartness of tobacco companies. They have really done their homework. They know their exact clientele and they have done an excellent job. So, we need to sort of counter that.


So just an estimate of the amount of money that they've spent on marketing. In 2017, apparently, they spent $8.6 billion on marketing. So, if you look at it, it's actually like $23 million a day. So almost like $1 million an hour spent on marketing these e-cigarette products.


We should not assume that our kids are not aware of these e-cigarettes, because about 80% of middle and high school students have been exposed to some bit of advertising or they know. So, the way these products is packaged is they make it look bright and very attractive. These products are displayed along with usual household items.




The names of these and the flavors are a big factor. For example, they have things like refreshing citrus or spiced crumb or like a cheesecake, things like that. So, kids are like, "Oh, this is what I eat at home, man. What's the harm in inhaling something like this?" So, the way they have marketed is, you know.


And now, these fourth-generation cartridges, they look like flash drives. So, it's very easy to hide and it's very discrete. So, unless parents or teachers are aware of this, it's very easy to miss.


Regarding marketing, flavor is the tobacco company's biggest friend. So, they have capitalized on that.


The other thing they do is they advertise through social media. So, this is where the kids are, and this is exactly where they're going to. So, there are a lot of influencers, celebrities who vape, and they are trying to be role models for these kids. They do sponsor music festivals and events where they have like vape booths, people can go trial. Even though there's rules on age limit, nobody's watching what they're doing.




I was also surprised to see that they're offering scholarships to kids, those who write essays on the advantages of vaping.

And one of the interesting things was there is also race-based marketing. So, tobacco companies are targeting some ethnicities like African American ethnicities. They are targeting menthol products to them.


So, they have a lot of money. They know exactly what they are doing, so we need to be smarter to counter their efforts.


Dr. Mike Patrick: Yeah, absolutely. I want to pull out two things that you said to highlight. So, a million dollars a day in marketing. That tells you how much they're making off of these things.


Dr. Grace Paul: A million dollars an hour.


Dr. Mike Patrick: Oh, a million dollars an hour on marketing. So, they're making billion off of something that is addicting. And like you said, using celebrities on social media to reach kids and having these devices be very colorful.




And you mentioned some of the names. And not that I want to advertise specific products, but like the Puff Bar, for example, it just has a cool sounding name. Juul is a cool sounding name. And there's so many others of them out there, the Hype, Puff, HIT, Mody, the Mngo stick. There's so many that really sort of appeal to young folks.


And then I was running through some of the flavors. And I mean, you could see how someone would want to try peach green tea or banana nut bread or frozen lime drop. I mean, the USA blend is described as musky cowboy. Just really making people feel that this is something that they want to do.


Dr. Eric Mull: Yeah. And if the listeners want to do a quick Internet search on images on what flavors for these cartridges look like, you'll get pages and pages of what look like candy stores. There's very bright packaging, some have cookies on them. Some have pictures of pies on them to kind of represent the flavors.




Dr. Paul and I, we obviously don't use these devices, but we needed to get our hands-on experience too as well. So, we've made personal trips to these types of shops to kind of learn about the devices, kind of learn about the flavors. And you'd be surprised about how the way they present these flavors, cartridges, packages, and even the devices. It really is what appears to be a very clever marketing.


Dr. Mike Patrick: Do they offer you a free sample?


Dr. Eric Mull: We were upfront about our efforts trying to learn about the devices. And they were very forthcoming with giving us information about how they're used, which is very nice of them. But to touch back on the free samples, that's actually one of the few things that's illegal based on the FDA, thankfully.


Dr. Mike Patrick: All right. Nationally?


Dr. Eric Mull: Nationally.


Dr. Mike Patrick: Nationally, okay, all right, so I should not ask for a free sample.




Dr. Eric Mull: Right.


Dr. Mike Patrick: I'm not going to go in there though. I can guarantee that.


I'm glad you brought up laws regarding vaping. I did want to talk about the state of vaping legislation and policy at the federal level. I remember before the pandemic, it was a big deal that we're going to try to get rid of the flavored products completely, ban them, outlaw them. But that didn't really come to pass, did it?


Dr. Eric Mull: It did not. So, I grew up in the 90s, not to put an age on myself. But I remembered when flavored cigarettes were a thing, and when they were finally getting off the market. And I mentioned earlier that electronic cigarettes, they first came into the US market in 2006.


It wasn't until 2016 that they were actually classified based on wording of the laws, that they were regulated by the FDA, which is something called the Deeming Ruling. And based on that, they have the same regulations as conventional cigarettes for the fact that you can't get free samples. You can't buy them from vending machines. You can't sell nationally to anyone less than 21 years of age.


So nationally, the FDA is the one that is managing the cigarettes. So, they're able to dictate how they're manufactured, but it's really left to the individual states on how they're sold and how they're distributed to the population.




And so, most states, and thankfully Ohio is one of those states, has increased that age limit to 21 years or older.


And then, just to backtrack slightly as well, the FDA also requires that cartridges, the pre-made cartridges can't be flavored. And the pre-made cartridges have to child-safe to prevent death.


But as we mentioned, there's a lot of user variability with these devices, a lot of user accessibility too as well, where you're able to create your own flavors, your own substances. And so, they get around that loophole about not having flavors because they make their own cartridges.


Dr. Mike Patrick: Originally, they're going to get rid of all the flavors but then the vape shops lobbied and said "Well, you're going to shut us done and we won't be able to make money and have a business if we don't have flavors." And so, you can still get flavors when you go into the vape shop, right? Because they're the ones that put those together.




Dr. Eric Mull: Yeah, you either have to buy them online at certain websites or you have to go to the physical shops themselves. And they'll make cartridges for you. But as mentioned, the pre-made cartridges that you could just buy won't be flavored.


Dr. Mike Patrick: But that's not really stopped youth vapers, right? They're going to find a way to get those products even though you can only get them online or in a vape shop.


Dr. Eric Mull: Yeah, and if you look at that survey, the National Youth Tobacco Survey, majority of people that do vape in the adolescence or young adult group are using flavors. I think it was up to 83% are using flavors.


Dr. Mike Patrick: So, they're getting it somewhere.


Dr. Eric Mull: They are, exactly.


Dr. Mike Patrick: So that's on the federal level. But states and communities can also regulate these products, right?


Dr. Grace Paul: Yes, absolutely. So, from Ohio, one of the biggest things is we are acknowledging the problem. So why it has become a public health issue is now, the concern is that we are re-normalizing smoking by allowing these in quotes, "safer alternative".


So that is one concern, because all the work done by so many agencies to curb smoking, as now we are having this alternate product, which could completely negate all that work.




Another important thing to note is in Ohio, compared to the nation, our rates of smoking any tobacco including e-cigarettes is much higher among the high school population. So, it is a true problem here.


At the state level, we do follow the FDA's rule, like the excellent Tobacco 21 Rule. There's a multiple flavor ban. So that was a sort of from a legislative standpoint. And from a community standpoint, there's many things we can do. There are things that a pediatrician can do, things that schools can do.


So, what I think pediatricians can do, one is first of all, knowing what the problem is and acknowledging it. So, the American Academy of Pediatrics has encouraged early screening, as early as 11 years of age. And it's important to have this relationship with your patient and to make them trust you and to ensure confidentiality because this is a very sensitive issue.




So, preventing starting of vaping is important, so focusing a lot on education and directing teenagers and parents to some validated national public education prevention campaign is important. Some of the examples are The Real Cost campaign, Safer ≠ Safe Campaign, The Truth Initiative, and then the Tobacco Free Kids Campaign. These are all excellent websites that as a pediatrician we can help.


From a quitting standpoint, again, once we know that there's a problem, you can offer some resources. In Ohio, we have some excellent resources. They are the Ohio Quick Line, the My Life My Quit Program, and This Is Quitting Program.


So, all of these, what they offer is to connect with the particular individual through social media, texting and create personalized quitting plans.




Dr. Mike Patrick: We'll put links to many of those resources that you mentioned in the show notes over at pediacast.org, so folks can find them easily.


If you're wondering what the state of vaping legislation is in your particular state, we'll also have some links for you there. Vaping Laws by State in 2021 from the World Population Review, STATE System E-Cigarette Fact Sheet from the CDC, and States and Communities with Restricted Sales of Flavored Products on the site Tobacco-Free Kids. And we'll put links to all of those things so folks can find it easily.


Here in the state of Ohio, I think it's 18 or 21 is the…


Dr. Grace Paul: Twenty-one.


Dr. Mike Patrick: Twenty-one now. That's fairly new, right?


Dr. Eric Mull: It is. I think that came about in 2019 after much lobbying and legislation.


Dr. Mike Patrick: Because it was 18 before then.


Dr. Eric Mull: It was.


Dr. Mike Patrick: But there's plenty of states where it still is 18, too.


Dr. Eric Mull: Yes.


Dr. Mike Patrick: So, there's lots that the federal government can do, the states can do, that communities and pediatrician can do. What about parents? What is their role in combatting the hazards of vaping?




Dr. Grace Paul: So, one of the things, as with anything else, prevention is better than cure. So open communication and not denying that your child is actually exposed to this or using this. That is one factor that we see in our clinics, is parents are like, "My child doesn't vape." But then when you talk to the kids separately, they do acknowledge that they're doing it.


So, a way for parents to identify vaping was based on those smells, the mood of the child, declining school performance. That was one thing. Another factor is, again, ensuring a tobacco-free home. If a parent smokes, what is the incentive for the child? You're not really being a role model for your child. So, ensuring a tobacco-free home.


And then, for the parent to know what are the products, what are the complications, so CDC and the AAP and Ohio Department of Health, they all have a lot of information. So, I would refer parents to that instead of Google, where you can just get some wrong information.




And parents can also refer their kids directly to this specific quitting resources. And finally, the success is when there is a collective approach between a parent, a child, and the physician in a very non-confrontational patient systematic manner. That's the only way to get us or have a successful outcome against this.


The other part is a parent's involvement in schools and advocating in your neighborhood and community. That can also be very valuable.


Dr. Mike Patrick: So, tobacco-free home. And so, if you are a parent who smokes tobacco products or vaping products, really, try to make a commitment to stop and be a good role model for your kids or don't start doing it.


And then, I think really that having honest, safe, open conversations and knowing what your kids are doing and talking about the hazards of it and then helping them get help to stop. But not necessarily in a negative judgmental way that's just going to force them to do it when you're not looking. You'd rather know about it.




And definitely talk to your doctor or your pediatrician for guidance on quitting because it's really, really important. It could save many years of your life and a lot of trouble and hardship down the road for sure.


Well, we really appreciate both of you stopping by and talking to us today. I know the Division of Pulmonary Medicine at Nationwide Children's Hospital is very busy. It's not just vaping lung injury that you take care of, right? Tell us a little bit more about your division.


Dr. Grace Paul: So, Eric and I are very proud of our Pulmonary Division. We are ranked seventh best pediatric pulmonary program, according to US News Reports.


Dr. Mike Patrick: It's really number one though.


Dr. Eric Mull: In my heart it is.






Dr. Grace Paul: So, we are a team of 18 doctors and 6 fellows. But we are very well supported by a great multidisciplinary team on the inpatient side and outpatient side. Our clinics, we have general pulmonary issues, cystic fibrosis. We have a sleep clinic, neuromuscular lung transplant. And then newer clinics are the sickle cell disease, PCD, interstitial lung disease, so a lot of these clinics.


We do take care of patients from like NICU graduates, from infants to many adults with complex medical needs. We feel we're very good at taking care of chronic mechanical ventilation issues. Apart from a strong clinical division, we are also actively participating in many clinical and translational research. And then, many members of our team are part of national and international committees.


The other thing which we are proud of is our team has been called to our local suburban schools, to come into the schools and teach our high schoolers about vaping and ill effects. So, it was like an invitation for us, which it's an honor to go as a team with our fellows, go meet kids, understand actually what's going on. That has also been something that we are very honored, and we feel it's very valuable.




Dr. Mike Patrick: And when you are in the schools, you guys have asthma clinics in the schools as well, right?


Dr. Grace Paul: So, we have that. We have some school-based asthma therapy programs. So, our going there and actually talking to the kids, that really opens our eyes to what actually goes on.


Dr. Mike Patrick: Yeah, absolutely. And then Eric, we mentioned that you are a pulmonary fellow. What does that mean? What is a pulmonary fellow? And tell us about the Pulmonary Fellowship Program.


Dr. Eric Mull: So, I'm at the tail end of my long career and long journey of medical education. So, after four years of undergraduate, four years of medical school, three years of residency, becoming a board-certified pediatrician that is eligible to work in the community without supervision seeing children, I decided to pursue fellowship, which is to get specialized training in pulmonary medicine. Which is the field of the lungs and everything associated with the diseases of the lungs.




So, I am currently an independent general board-certified pediatrician.  But now, I'm currently training at the end of my three years for fellowship to be a pulmonologist. And I'm very fortunate here to be training at one of the highest institutions in the country.


And now that I'm in my third and final year of fellowship and I'm starting to interview for my big boy jobs after this, I'm starting to see just how in high regards every institution regard Nationwide and the training that they provide here for their pulmonary program.


Dr. Mike Patrick: Yeah, that's really really good to hear and good luck to you on your future endeavors for sure.


We are going to have lots of links in the show notes. So just look at listening to the podcast as part one of exploring e-cigarettes and the hazards of vaping. And then, definitely go to the website over at pediacast.org, look for the show notes for this episode, 508, and there'll be lots of links to great resources. So be sure to check that out.




All right, well, Dr. Grace Paul and Dr. Eric Mull, both with Pulmonary Medicine at Nationwide Children's Hospital, thanks again so much for stopping by today.


Dr. Grace Paul: Thank you so much.


Dr. Eric Mull: Thank you for having us.




Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.




Also, thanks once again to our guests, Dr. Grace Paul, pulmonary medicine specialist at Nationwide Children's Hospital, and Dr. Eric Mull, pediatric pulmonary fellow.


Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


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And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements. Of course, you want to be sure the content of the episode matches your scope of practice.


Shows and details are available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.


So, before we go, one more time, I want to wish all of you the merriest of holidays. I just hope you have a wonderful time with your family and friends.


Thanks again for stopping by. And until next time, which will be in 2022, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.






Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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